Analysis of the evaluation performance of cadres care stunting in efforts to prevent stunting

Stunting is a condition in which a child experiences growth disturbances so that the child's height is lower or shorter than the standard age. One of the efforts to prevent stunting is by providing assistance to pregnant women. Cadres as the spearhead of health workers who are near pregnant women and mothers with toddlers are expected to be able to monitor pregnant women and mothers with toddlers in efforts to prevent stunting. This study aims to analyze the evaluation of the performance of cadres in efforts to prevent stunting. The study used qualitative methods with in-depth interviews with four key informants and focus group discussions . In-depth interviews were conducted with 4 health cadres, and a Focus Group Discussion involving the Leaders of Organization of regional apparatus for family planning affairs , District Bappeda, Village Government, Health Center and Nutrition service staff. The data is then processed through the content analysis method. The data is then reduced through a coding process, summarized and drilled into partitions or sections that focus on questions. The results of the study show that, until now there has been no specific program in the context of efforts to prevent stunting to be carried out by cadres, even though there are currently various types of cadres besides health cadres who are known to be at posyandu, there are also other cadres who formed for the prevention of stunting, however, the implementation of the tasks has not been maximized because there is no specific program that is used as a reference in carrying out the tasks. In conclusion, that the performance of cadres is currently not optimal and focused on efforts to prevent stunting.


Introduction
Stunting is a condition where children experience growth disorders until their height is lower or shorter than the age standard.In Indonesia, children who become stunted are proof of the poor quality of Human Resources (HR) because it can reduce productivity and have an impact on the economy (Wicaksono et al., 2022).This condition occurs due to a person not getting the right amount of nutritional intake for a long time.If left unchecked, it will cause children to do less well in school, and when adults become less productive, income decreases, and it will continue to be below the poverty line.The problem of stunting cannot be underestimated.If this problem is allowed to continue, it will become a burden as well as a serious threat to the future of the nation.Globally, stunting contributes to 15-17 percent of all child deaths in the world (Direktorat Jenderal Informasi dan Komunikasi Publik, 2019).
Stunting is a toddler problem that currently occurs in various regions.The occurrence of stunting in toddlers often goes unnoticed, and after two years, the toddler looks short (Hidayati et al., 2022).In Indonesia, the main cause of stunting is also found to be the low provision of proper nutrition for children aged 0-5 years (Arbie & Labatjo, 2019).In addition, the nutritional status of the mother before and during pregnancy can affect the growth of the fetus.If the mother's nutritional status is normal before and during pregnancy, she will most likely give birth to a healthy fullterm baby with normal weight (Adibin et al., 2022).The results of research conducted by Lubis et al., show that in addition to maternal age, maternal height, maternal education, and socioeconomic status also affect stunting in children (Lubis et al., 2022).
The problem of stunting has been identified mostly among Indonesian children aged 0-5 years who are born with low body weight, including those from rural and poor families, and who have low malnutrition-rich diets.Thus, overall, it can be concluded that stunting is a major problem in infants that can be overcome by providing proper nutrition to children (Arbie & Labatjo, 2019).The problem of stunting is directly related to reduced brain ability, an underdeveloped mind, and longlasting adverse consequences such as poor learning ability and inadequate performance in school (Arbie & Labatjo, 2019).Another study that looked at risk factors for stunting was conducted by Asnidar et al., who found that there was a significant relationship between Antenatal Care (ANC) service factors, breast milk, and consumption of Fe tablets with the incidence of stunting in preschool children in Ujung Bulu District (Asnidar et al., 2022).Women who have started birth checkups during the first trimester have fewer complications during their pregnancy (Akhila et al., 2022).
Currently, in Indonesia, one of the efforts to accelerate stunting reduction is carried out by implementing eight convergence actions in various regions.However, not all regions that implement these efforts can carry them out optimally.One of the studies conducted by Absori et al., stated that, in reality, the eight convergent policies were ineffective because their implementation was incomplete, even though they had been well formulated (Absori et al., 2022) The main focus in handling stunting is to provide specific nutritional interventions in the First 1000 Days of Life (1000 HPK).One of the efforts in implementing interventions in 1000 HPK is the use of posyandu.Meanwhile, posyandu services cannot be separated from the participation of cadres, which is the main driving force for the implementation of posyandu.In general, the task of nutritionrelated health cadres is to collect and measure weight and length/height, which are then recorded on the Health Card (HC), provide additional food and vitamin A, and conduct nutrition counseling.Meanwhile, cadres must also refer to the Puskesmas if there are toddlers with weight loss or no weight gain in two consecutive months (Mediani et al., 2020).However, based on the reality in certain areas, there are still many cadres who do not understand their duties well.So it is necessary to evaluate the implementation of the duties of cadres in the field.
Cadres are usually trained to identify individual and community health problems; hence, they can engage in health promotion, provide counseling, and refer medical problems to health care facilities (Siswati et al., 2022).Results of research conducted by Mediani et al. (2020) indicate that there is a need for a specific cadre empowerment program in the management of nutrition in an effort to prevent stunting in toddlers.This study aims to analyze the implementation of cadre performance in the community related to stunting prevention efforts.This is the first step to seeing an analysis of improvements to cadre performance in Central Mamuju Regency.

Methods
This research is a case study with a qualitative approach using in-depth interviews and focus group discussions as data collection methods.The subjects in the in-depth interview were four health cadres, while the subjects in the focus group discussion consisted of the Head of the Puskesmas, Head of the Regional Apparatus Organization Division, Village Head, Bappeda Representative, and several nutrition officers at the health center.
Data collection was conducted using indepth interview and focus group discussion (FGD) techniques.The in-depth interview covered several aspects, including: 1) cadre work programs and specific cadre work programs regarding stunting 2) Implementation of nutritional status monitoring by cadres 3) Data on toddlers in Posyandu that can be used to detect stunting 4) The program should focus on the tasks of cadres.Meanwhile, the FGD was carried out to obtain information on the performance of cadres in an effort to accelerate stunting reduction from OPD KB, Puskemas, village, and TPG leaders in their respective regions who collaborated with cadres.
Data processing is carried out through the content analysis method, which is a qualitative data processing technique that evaluates data details and patterns.Data is identified based on frequently occurring words.Data reduction begins with the process of coding, summarizing, and also creating partitions or parts that focus on the purpose of the question.
This research has received ethical approval from the ethics commission of the Makassar Ministry of Health Poltekkes with Number No. 703 /KEPK-PTKMS /VII/2022.

Result and Discussion
The results of this study are elaborated based on the conclusions of each indicator measured to see the extent to which cadre performance is related to stunting prevention.

Cadres work program
According to Kader Nu, about the cadre work program so far as well as cadre work programs related to stunting, namely, "For now, there is none, if the previous one is just chasing the scale.From the results of in-depth interviews with four informants, researchers concluded that there was no consistent work program for cadres.The work carried out by cadres so far depends on the ISC where they serve; the more effectively the posyandu officers give work instructions to cadres, the more things are done by cadres.

Nutritional Status Monitoring Implementer
According to Nd cadres: "Yes, just measure, rich in the registration section only, weighing measured height and head circumference, for example.If you go down again on the scale, yes, you are given more counseling." Meanwhile, the cadres of An, HL, and Nu, in order are: "The job description is five tables, starting from the registration desk, weighing, to the register, counseling, then checking and reporting the data, which is carried out after the ISC is completed, first reporting to the village midwife or vice versa from the midwife, who asks first, and sometimes from nutrition, who also asks.""Reporting each boast, we make a report on the development of the baby's growth through weighing every month.There is registration.We have to report this immunization, and then there are also those from the health center who intervene directly themselves to take the data.""My job description at the ISC is to measure the height and head circumference of a toddler.For recording, I divided the tasks with five other cadres, and each had responsibilities that had to be completed.When the posyandu activities were completed, the data we filled in we immediately reported at that time."Data on toddlers in ISC that can be used to detect stunting One of the evaluation indicators measured as part of the implementation of cadres' duties is the availability of data on toddlers in each posyandu owned by cadres for detecting stunting.Based on the results of interviews conducted in depth with four informants, information was obtained that, so far, data on toddlers to detect stunting can be found clearly and completely at ISC.However, there are still cadres who state that the completeness of the data comes from midwives and nutrition officers.

Programs that should preferably be on the task of cadres
Questions about programs that should be carried out by cadres to prevent stunting were also asked to informants in this study, and overall, informants answered that prevention should be carried out during pregnancy by providing counseling and assistance.This is as stated by An's informant, among others: "Cadres need to pay attention starting from their pregnant women, at least once a month given motivation to maintain pregnancy and provide counseling so that the child in the womb is healthy, always reminding parents to continue to bring their toddlers to the ISC so that they can continue to monitor the growth and development of their children, and also the bride and groom (future bride and groom/catin) must be given training first.In my opinion, that is what cadres need to pay attention to in stunting prevention." Results of research conducted by Windasari et al. (2020) stated that several factors related to the incidence of stunting in toddlers in the work area of the Makassar Tamalate Health Center include the noninitiation of early breastfeeding and exclusive breastfeeding that is not obtained by toddlers.For this reason, if there are cadres in the community who are used as companions for Salim & Muslimin pregnant women until mothers who have children with the age of the First 1000 DL, then it is likely to be a bridge to help mothers fulfill maximum EBI and breastfeeding.
Health cadres who are currently in the midst of the community come with various limitations; the main task is considered only as an assistant to health workers in the field when carrying out ISC; areas with cadres of only a few people who are active do not even rule out the possibility that there are posyandu that have cadres who are not active at all; while cadres are the closest people and are among pregnant women and mothers who have toddlers, their role is needed if good management can be carried out.
Focus Group Discussion (FGD) was also conducted to obtain information on the performance of cadres in an effort to accelerate stunting reduction from the Regional Apparatus Organization (RAO) in the field of Family Planning (FP/Keluarga Berencana/KB), the health center, village, and TPG leaders in their respective areas who collaborated with cadres.
The results of the evaluation of cadre performance based on the implementation of the FGD are as follows: The performance of cadres is based on information from OPD KB and BAPPEDA leaders In terms of stunting prevention, currently in the village, a family assistance team has been formed consisting of 3 people (from PKK/Family Welfare Empowerment/FWE, FP cadres, health cadres, and midwives in the village), but related to performance as a PKK team, until now there has been no action in the field.
Cadre performance based on information from the village.The existence of cadres in the village already exists, but for science, it is still very minimal.In Sinabatta Village, there are 15 cadres, consisting of 10 cadres from 2 posyandu and 5 youth cadres.These adolescent cadres need to be equipped with specific knowledge in an effort to prevent stunting.
Stunting caused by multiple factors can be prevented by making various efforts as early as possible.If cadres can carry out their roles and functions well, in this case by helping to detect malnutrition early and report it to relevant parties, then cadres will help improve the child's health status (Santi et al., 2020).
One example of efforts that can be made is through good cadre training management.For example, the results of research on the evaluation of cadre training management show that problem-based and conventional learning methods improve cadre knowledge and skills.The BBM method increases the knowledge and skills of cadres more than conventional methods.Cadre satisfaction is higher when using the BBM method compared to conventional methods (Rostinah et al., 2015).
Stunting is influenced by several factors.These factors should be known by cadres, who will then oversee stunting prevention efforts at the closest level to the community, especially pregnant women and mothers with toddlers.Various studies have been carried out and have become a source of information related to factors related to stunting.Mutiasari et al. stated that there is a correlation between the level of knowledge and the incidence of stunting and that the improvement of the nutritional status of family members will be achieved if the family, especially the mother, has sufficient nutritional knowledge (Absori et al., 2022).The challenge of implementing stunting prevention efforts is related to the fulfillment of unbalanced nutrition (Tampubolon et al., 2021).Another supporting research result is that one of the efforts to recall the health approach material provided is through learning methods such as simulations and demonstrations (Rahim & Muslimin, 2019).Another thing to note is that regular weight measurement can describe the nutritional state of children, so it can be used as part of the monitoring of children's physical growth.Body weight is a sensitive measure that is strongly influenced by changes in nutritional status.At the Puskesmas or field level, the determination of nutritional status is generally carried out by weighing toddlers (body weight per age) (Erlyn et al., 2021).
The results of another study stated that the results showed that the main driver of the reduction in stunting prevalence was investment in social health insurance programs.The results also showed that the greatest decrease in stunting occurred when the incomes of some of the poorest groups increased.Other consistent drivers of lower stunting prevalence are increased urbanization, population density, and diphtheria, pertussis, and tetanus/DPT vaccination rates (Bowser et al., 2016).
Understanding the various factors that cause stunting is important and becomes the basic requirement for cadres to improve their performance.In addition to needing to understand the causes of stunting, cadres also need to understand their duties in the implementation of ISC, for example.Each cadre needs to understand the duties of the five tables in the implementation of posyandu (Aprianti et al., 2020).The Posyandu program is one of the priorities to improve health services at the village level (Wicaksono et al., 2022;Rahmad et al., 2022).
In addition to knowledge and motivation, the skills of ISC cadres are one of the keys to the success of the service system at Posyandu (Purwanti, 2019).The assistance carried out by cadres is very beneficial for mothers of toddlers (Faridi et al., 2020).The more active a cadre is, it can be a reflection that the cadre's performance is getting better.Cadres are sukarea energy that has the potential to be able to move community because they are part of the community.The performance of cadres certainly needs attention from the government and local community leaders (Setiyawan & Mardhianti, 2013).The same thing was also revealed by Afifa in her research: the higher the motivation possessed by cadres, the better their performance will be (Wicaksono et al., 2022).Stunting prevention and handling must be carried out in a coordinated manner that is able to actively involve all government structures (Nasrul Z et al., 2022).

Conclusion
The results showed that until now there has been no special program in the context of stunting prevention efforts to be implemented by cadres.Although, in the community, there are various types of cadres, in addition to health cadres who have been known to be in posyandu, there are also other cadres formed for stunting prevention, but the implementation of duties has not been optimal because there has been no special program used as a reference in the implementation of duties.
Based on the results of this study, it is necessary to optimize the role of cadres, starting with the preparation of clear program indicators, which then need to be evaluated regularly so that the existence of cadres in the community can be seen as having benefits.
4%, the second largest after East Nusa Tenggara, and in 2016 it was 39,7%, the highest percentage of all provinces.In 2017, the percentage increased again to 40.1% and ranked second largest after NTT, and in 2018, the prevalence of stunting in West Sulawesi was the second highest nationally after NTT (Kementerian Kesehatan RI, 2021).From 2019 to 2022, the stunting rate in West Sulawesi was 40,38%.Central Mamuju Regency is one of six districts in West Sulawesi that still have areas or villages in the Stunting Locus Category.In 2020, Sibatta Village will be one of 10 villages categorized as Stunting Locus by the Central Mamuju Regency Government.